Effect of preoperative chemotherapy on the histopathological classification of gastric cancer.

BACKGROUND: In the era of individualized gastric cancer (GC) treatment, accurate determination of histological subtype becomes increasingly relevant. As yet, it is unclear whether preoperative chemotherapy may affect the histological subtype. The aim of this study was to assess concordance in histological subtype between pretreatment biopsies and surgical resection specimens before and after the introduction of perioperative treatment. METHODS: Histological subtype was centrally determined in paired GC biopsies and surgical resection specimens of patients treated with either surgery alone (SA) in the Dutch D1/D2 study or with preoperative chemotherapy (CT) in the CRITICS trial. The histological subtype as determined in the resection specimen was considered the gold standard. Concordance rates and sensitivity and specificity of intestinal, diffuse, mixed, and "other" subtypes of GC were analyzed. RESULTS: In total, 105 and 515 pairs of GC biopsies and resection specimens of patients treated in the SA and CT cohorts, respectively, were included. Overall concordance in the histological subtype was 72% in the SA and 74% in the CT cohort and substantially higher in the diffuse subtype (83% and 86%) compared to the intestinal (70% and 74%), mixed (21% and 33%) and "other" subtypes (54% and 54%). In the SA cohort, sensitivities and specificities were 0.88 and 0.71 in the intestinal, 0.67 and 0.93 in the diffuse, 0.20 and 0.98 in the mixed, and 0.50 and 0.93 in the "other" subtypes, respectively. CONCLUSION: Our results suggest that accurate determination of histological subtype on gastric cancer biopsies is suboptimal but that the impact of preoperative chemotherapy on histological subtype is negligible.

Parental sun-protective regimens and prevalence of common melanocytic naevi among 7-year-old children in Sweden: changes over a 5-year period.

BACKGROUND: Common melanocytic naevi and cutaneous malignant melanoma share a common risk profile, influenced by ultraviolet radiation exposure. A high density of common melanocytic naevi correlates with an increased lifetime risk of developing cutaneous malignant melanoma. Effective strategies for sun protection, starting in early childhood, are considered of great importance to reduce the steadily rising melanoma trend. OBJECTIVES: To investigate the 5-year changes in sun tanning habits, sun-protective regimens and density of common melanocytic naevi between two age-standardized populations of children. METHODS: Population-based cross-sectional study performed among 7-year-old children in southern Sweden in 2002 and 2007. The parents answered a questionnaire and all children were examined by the same, trained research nurse. RESULTS: In total, 1190 children were enrolled: 681 in 2002 and 509 in 2007. The results showed that sun-protective regimens, such as use of sunscreen (+29%), clothing (+30%), staying in the shade (+123%) or indoors (+136%) during peak sun hours, had all increased significantly (P<0·0001). Travelling to sunny seaside holiday resorts abroad before the age of 2years had almost doubled (P<0·0001). The adjusted mean number of naevi per square metre body surface was significantly (P<0·0001) lower in 2007: 6·6 [95% confidence interval (CI) 5·6-7·6], compared with 11·0 (95% CI 10·0-12·0) in 2002. CONCLUSIONS: This study demonstrates increased self-reported parental actions for sun protection of young Swedish children in recent years; in consistency, lower numbers of common melanocytic naevi were observed. Results support the use of common melanocytic naevi as an objective measure of sun exposure in children.

Cancer risk in offspring of male pesticide applicators in agriculture in Sweden.

AIMS: To explore cancer risk from date of birth until 1994 in children, born 1958 or later, of Swedish male pesticide applicators. METHODS: Records of male pesticide applicators licensed 1965-76 were linked to the Multigeneration Register. The records of their offspring were then linked to the Swedish Cancer Registry and the Cause of Death Register. RESULTS: In total 51 cases of cancer were observed, which is significantly lower than the expected 73.0 (standardised incidence ratio (SIR) 0.70, 95% CI 0.52 to 0.92). Tumours of the nervous system was most common, amounting to 20 cases, 39% of all cancer cases (SIR 1.01, 95% CI 0.62 to 1.56). A statistically significant reduced risk for leukaemia was found (SIR 0.43, 95% CI 0.19 to 0.86). For non-Hodgkin's lymphoma, three cases were observed and 4.8 expected (SIR 0.63, 95% CI 0.13 to 1.83). For Hodgkin's disease, five cases were observed versus 3.7 expected (SIR 1.36, 95% CI 0.44 to 3.17). Two cases of testicular cancer were observed and 1.7 expected (SIR 1.19, 95% CI 0.13 to 4.28). CONCLUSIONS: None of the a priori hypotheses of increased risk of tumours of the nervous system, kidney cancer, leukaemia, lymphoma, soft tissue sarcoma, and testicular cancer in children of male pesticide applicators could be confirmed.

Counselling and communication in hospital dentistry.

Many of the people who are members of hospital dental teams are highly motivated, caring individuals. Unfortunately, though, they are not given the kind of training or support that is necessary to enable them to perform their tasks most effectively. This study was initiated at a hospital dental clinic where burdensome cutbacks and reorganization had been keenly felt by the personnel. A counselling group was formed under the leadership of a professional counsellor, and in the course of the year there were seven meetings, each of which lasted 1.5-2 hours. The open way in which counselling was designed presented opportunities for the six group members to influence the topics of each meeting, something all of them preferred to more structured sessions. Different stress factors in the environment were discussed. The group members concluded that the counselling programme had increased their self-esteem and facilitated effective communication between the group and patients by giving them all the opportunity to discuss barriers and confusing clinical situations. Counselling had also facilitated interpersonal relationships between the team members by revealing hierarchical difficulties. Apart from the clear humanitarian need for counselling there is a good economic argument. Effective staff support is not a luxury, nor is it a waste of time. Adequate time for counselling must be provided, simply.

Endophthalmitis after cataract surgery: risk factors relating to technique and events of the operation and patient history: a retrospective case-control study.

OBJECTIVE: This study aimed to investigate the relationship between postoperative endophthalmitis and current changes in the cataract operative technique. DESIGN: A retrospective case-control study. PARTICIPANTS: The 22,091 cataract operations performed from 1990 through 1993 at St Eriks Hospital formed the basis for this investigation. In a random fashion, 220 control subjects were selected to be compared with the endophthalmitis cases. MAIN OUTCOME MEASURES: Numerous variables pertaining to the cataract extraction procedure and to the ocular and general health of patients with cataracts were analyzed regarding the development of postoperative intraocular infection. Patient age, presence of diabetes or immunosuppression, type of cataract extraction and intraocular lens (IOL), and intraoperative or postoperative complications were the principal variables assessed. RESULTS: Fifty-seven patients with endophthalmitis were diagnosed, resulting in an overall frequency of 0.26%. Immunosuppressive treatment (P = 0.019), wound abnormality (P = 0.03), and the use of IOLs without a heparinized surface (P = 0.0023) were the only significant risk factors found in a logistic regression model. CONCLUSIONS: The results suggest that cataract operating practice may alter the risk for endophthalmitis in that implanting a heparinized IOL and creating a tight section both seem to provide protection against this dreaded complication. Regarding patient history, an increased susceptibility was found among subjects treated with immunosuppressants. Designing a prophylactic protocol that protects against endophthalmitis more efficiently than did the study prophylaxis of 20 mg of subconjunctival gentamicin, is important not only for this patient subgroup but also for the cataract operated population at large.

Prostate cancer in pesticide applicators in Swedish agriculture.

BACKGROUND: The use of chemicals in agriculture has been associated with elevated risks of prostate cancer. The aim of this study was to analyze prostate cancer risk in a cohort of 20,025 pesticide applicators in agriculture licensed between 1965-1976. METHODS: The cohort was followed up in the Swedish Cancer Register from date of licence until death of December 31, 1991. The mean follow-up time was 21.3 years. RESULTS: We found a statistically significant increased risk of prostate cancer with 401 cases observed compared to 355 expected, with a standardized incidence ratio (SIR) of 1.13 (95% confidence interval: 1.02-1.24). There were 7 cases among those born in 1935 or later, and the SIR was 2.03 (0.82-4.19). For those born earlier than 1935 the SIR was 1.12 (1.01-1.24). CONCLUSIONS: These findings of a statistically significant increased risk of prostate cancer, together with recent results from other studies, imply a relationship between agrochemicals or other risk factors in the environment of farmers and prostate cancer.

[Low cancer risk among female agricultural workers]. / Låg cancerrisk bland kvinnliga lantbrukare.

In a cohort study of cancer incidence, 50,682 women registered in the 1970 Swedish census as engaged in agriculture were followed up in the national Cancer- Environment Register from 1971 to 1987. Instead of the expected incidence of 5,273 cases, a total of only 4,474 cases were found, yielding a significantly reduced standardised incidence ratio (SIR) of 0.85. Thus, site specific SIRs were also significantly reduced for cancer of the breast (0.83), cervix uteri (0.40), lung (0.46), urinary tract (0.57), and several other sites.

Cancer risks among male farmers in Sweden.

We have conducted a cohort study of cancer risks among 140,208 Swedish farmers in order to compare their cancer risks with those of the general male population. Since there were no individual data regarding exposure to agricultural chemicals and acquiring such data was not realistic, we obtained crude and hypothetical estimates for exposure by dividing the data into time periods, year-of-birth cohorts and geographical areas. The cohort was followed-up in the Cancer Environment Register from 1 January 1971 either until death or until 31 December 1987. The relative risk was computed as the ratio of the observed and expected number of cases (SIR = standardized incidence ratio). A total of 15,040 cases were observed vs 18,918 expected, resulting in a statistically significant decreased SIR of 0.80 (95% confidence interval: 0.78-0.81). The SIR was significantly decreased for several cancer sites, and the lowest value was found for tongue, lung, oesophagus, liver and urinary organs, which is in agreement with other studies on cancer risks among farmers. Other major cancer sites with decreased SIRs were the colon, rectum, pancreas and kidney. Lip cancer and multiple myeloma showed statistically significant increased risks. SIRs for stomach cancer, prostate cancer, skin carcinoma, malignant melanoma, tumours in connective tissue or muscle, malignant lymphomas and leukaemia were all close to unity, which is not consistent with several other studies that have shown increased risks for these sites. For malignant lymphomas the SIR increased over time, though not significantly, and was highest among younger farmers. The SIR for non-Hodgkin lymphoma was lowest in the northernmost region. This gives some support to the hypothesis that there is an association between non-Hodgkin lymphoma and exposure to pesticides and other agricultural chemicals. It is of note that the SIR for multiple myeloma was significantly increased in those parts of Sweden where the use of pesticides has been less frequent and in lower amounts.

Cancer risks among female farmers in Sweden.

There are few studies on cancer risks among female farmers, particularly on breast cancer and cancer in female genital organs. We have conducted a cohort study of cancer risk among 50,682 women with occupations in agriculture according to the Swedish 1970 census. The cohort was followed up in the nationwide, population-based, Cancer-Environment Register from 1 January 1971 until death or until 31 December 1987. Expected number of cases was based on annual cancer incidence in five-year age groups. The standardized incidence ratio (SIR) was computed as the ratio between observed and expected number of cases. A total of 4,474 cases of cancer were observed in the cohort from 1971 until 1987 cf 5,273 expected, resulting in a significantly decreased SIR of 0.85 (95 percent confidence interval [CI] = 0.82-0.87). SIR for breast cancer was significantly decreased (0.83, CI = 0.78-0.88), as was the SIR for cervix uteri (0.40, CI = 0.31-0.50). For the other female genital organs, SIR was close to one. Other cancer sites with significantly decreased SIRs were: colon (0.90, CI = 0.81-1.00); rectum (0.86, CI = 0.74-1.00); lung (0.46, CI = 0.37-0.57); kidney (0.81, CI = 0.68-0.97); urinary organs (0.57, CI = 0.45-0.72); connective tissue and muscle (0.62, CI = 0.39-0.95); and non-Hodgkin's lymphomas (0.78, CI = 0.63-0.96).

Cancer mortality after iodine-131 therapy for hyperthyroidism.

Cancer mortality was studied in 10,552 Swedish hyperthyroid patients treated with 131I between 1950 and 1975. The patients were matched with the Swedish Cause-of-Death Register and the cases of 977 patients who died from cancer or leukemia were studied. The patients had been followed up for an average of 15 years (range 0 to 35 years), and the overall standardized mortality ratio (SMR) was 1.09 [95% confidence interval (CI) = 1.03 to 1.16], with a higher risk for women. The highest mortality was seen during the first year after exposure (SMR = 1.15) and decreased for the following 9 years (SMR = 1.04). The risk of dying from a cancer in the digestive tract and respiratory organs was significantly elevated more than 10 years after exposure, as was the overall cancer mortality (SMR = 1.14). No increased risk was seen for leukemia, bladder cancer or breast cancer. Younger patients and those receiving 131I at higher activity had higher SMRs than older patients and those receiving lower activity. Patients with toxic nodular goiter had higher risk than those with Graves' disease. The lack of increasing mortality over time and with increasing activity of 131I administered argues against a carcinogenic effect of 131I. However, in the case of cancers of the stomach, the 131I exposure could have contributed to the excess mortality from these cancers.

Prediction of cancer mortality in the Nordic countries in 2005: effects of various interventions.

Rough estimates of the effect in 2005 of various preventive measures aimed at reducing cancer mortality in the Nordic countries were made using the American software CAN*TROL. The effect was measured as the percentage reduction in cancer mortality in 2005. The calculations were performed for changes in the smoking, dietary and sunbathing habits of the population (primary prevention), earlier diagnosis (secondary prevention) and improvements in survival resulting from better treatment (tertiary prevention). The calculations incorporate many assumptions, some of them more firmly based than others, such as uniformity of incidence trend in all the Nordic countries and also concerning the causality of various relations. For lack of evaluated Nordic data, we have used American figures concerning stage distributions and stage-specific relative survival rates. These assumptions should be borne in mind when drawing conclusions from the results obtained. The results show that there is a potential of up to several tens of percent for reducing total cancer mortality by the year 2005.

[Prediction of cancer mortality in Scandinavia in 2005. Effect of various interventions]. / Prediktion av cancermortaliteten i Norden år 2005. Effekt av olika interventioner.

Approximate estimates have been made of the effect by the year 2005 of various preventive measures to reduce cancer mortality in Scandinavia. Figures have been calculated for changes in smoking, diet and exposure to sunlight (primary prevention), for earlier diagnosis (secondary prevention), and improved survival as a result of improved treatment (tertiary prevention). The calculations have been performed with the American program CAN TROL, the effect being expressed as the percentage reduction in cancer mortality by the year 2005. The results give promise of a substantial overall reduction in cancer mortality in Scandinavia.

Cancer risk after iodine-131 therapy for hyperthyroidism.

Cancer incidence was studied in 10,552 patients (mean age, 57 years) who received 131I therapy (mean dose, 506 MBq) for hyperthyroidism between 1950 and 1975. Follow-up on these patients was continued for an average of 15 years. Record linkage with the Swedish Cancer Register for the period 1958-1985 identified 1543 cancers occurring 1 year or more after 131I treatment, and the standardized incidence ratio (SIR) was 1.06 (95% confidence interval = 1.01-1.11). Significantly increased SIRs were observed for cancers of the lung (SIR = 1.32; n = 105) and kidney (SIR = 1.39; n = 66). Among 10-year survivors, significantly elevated risks were seen for cancers of the stomach (SIR = 1.33; n = 58), kidney (SIR = 1.51; n = 37), and brain (SIR = 1.63; n = 30). Only the risk for stomach cancer, however, increased over time (P less than .05) and with increasing activity administered (P = not significant). The risk for malignant lymphoma was significantly below expectation (SIR = 0.53; n = 11). Overall cancer risk did not increase with administered 131I dose or with time since exposure. The absence of any increase in leukemia adds further support to the view that a radiation dose delivered gradually over time is less carcinogenic than the same total dose received over a short time. Only for stomach cancer was a possible radiogenic excess suggested.

Mortality among Swedish reindeer breeding Lapps in 1961-85.

We analyzed the mortality pattern among Swedish reindeer breeding Lapps, a unique group with a carefully preserved culture and a lifestyle that differs considerably from that of the rest of the population. The cohort consisted of 2,034 Lapps who were recorded in the 1960 Population and Housing census as members of a household where someone were occupied in reindeer breeding. The cohort was followed-up in the Swedish Cause-of-Death Register from January 1, 1961 until death or December 31, 1985. The total mortality was similar to that of the entire population. Four hundred and twenty eight deaths occurred and the standardized mortality ratio (SMR) was 0.95. Ischemic heart disease was the most frequent cause-of-death and the mortality was the same as in the general population (SMR = 0.95). Significantly lower mortality than expected was observed for malignant tumors (SMR = 0.70), diseases of the circulatory system (SMR = 0.68 and for diseases of the digestive system (SMR = 0.42). Significantly increased SMR was found for external causes of injury (SMR = 1.83) and among female Lapps for cerebrovascular diseases (SMR = 1.70). Female Lapps had a significantly higher mortality of diseases of the circulatory system (SMR = 1.19) in relation to males (SMR = 0.48).

Cancer risks in Swedish Lapps who breed reindeer.

Cancer risks during the period 1961-1984 were studied in a cohort of 2,034 Swedish reindeer-breeding Lapps, a unique group whose culture and life-style differ considerably from those in the rest of the Swedish population. A total of 100 cases of cancer were observed versus 163 expected. Statistically significantly decreased risks were found for cancers of the colon, respiratory organs, female breast, male genital organs, and kidneys, and for malignant lymphomas. The stomach was the only site with a significantly increased risk. Reindeer-breeding Lapps have ingested fallout products via the lichen-reindeer-man food chain since the 1950s. However, no increased risk was found for the cancer sites considered to be most sensitive to radiation.

Risk of cancer of the breast after legal abortion during first trimester: a Swedish register study.

An increase in induced abortions in Sweden has been accompanied by an increase in the incidence of breast cancer of about 40% in women aged 20-44. To assess whether the apparent risk is real the risk of breast cancer was investigated in practically all Swedish women with a history of a legal abortion in the first trimester before the age of 30 during 1966-74 (n = 49,000). The cohort was followed up in the Swedish cancer register to identify cases of breast cancer diagnosed more than five years after the abortion until the end of 1984. The number of observed cases of breast cancer was 65 compared with an expected number of 84.5, estimated from the contemporary Swedish population with due consideration to age, giving a relative risk of 0.8 (95% confidence interval 0.58 to 0.99). Contrary to most earlier reports, this study did not indicate any overall increased risk of breast cancer after an induced abortion in the first trimester in young women.

Risk of cancer in pesticide applicators in Swedish agriculture.

The risk of cancer was analysed in a cohort of 20,245 licensed pesticide applicators in agriculture who had licences issued between 1965 and 1976. Most were men (99%) and about 50% had been born in 1935 or later. The cohort was followed up in the Swedish Cancer Register from date of licence until death or 31 December 1982. The mean follow up time was 12.2 years. Average time since first exposure was longer, however, since one fifth of the cohort was exposed in the 1950s. A total of 558 malignant tumours was found compared with 649.8 expected, which resulted in a statistically significantly decreased standardised incidence ratio (SIR) of 0.86 (95% confidence interval (CI): 0.79-0.93). Significantly decreased risks of cancer were also found for liver (SIR = 0.45, 95% CI: 0.18-0.93), pancreas (SIR = 0.50, 95% CI: 0.26-0.87), lung (SIR = 0.50, 95% CI: 0.35-0.68), and kidney (SIR = 0.53, 95% CI: 0.32-0.84). No statistically significantly increased risks or any time trends were observed. SIR for testicular cancer was increased (SIR = 1.55, 95% CI: 0.92-2.45) and increased with period since licence. Eighteen cases with testicular cancer were found. For those born in 1935 or later a non-significant increased overall risk of cancer was observed (SIR = 1.07, 95% CI: 0.82-1.37). Comparisons were made with agricultural workers in general since pesticide applicators are mainly farmers that use or have used pesticides to a greater extent. Higher risks for pesticide applicators were found for testicular cancer, tumours of the nervous system and endocrine glands, and Hodgkin's disease.